Provider Demographics
NPI:1083882633
Name:DAVID C JACKS MD PA
Entity Type:Organization
Organization Name:DAVID C JACKS MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING MANAGER/ NURSE
Authorized Official - Prefix:MRS
Authorized Official - First Name:JUDY
Authorized Official - Middle Name:
Authorized Official - Last Name:FRIZIELLE
Authorized Official - Suffix:
Authorized Official - Credentials:LPN
Authorized Official - Phone:870-535-4221
Mailing Address - Street 1:4303 S MULBERRY ST
Mailing Address - Street 2:
Mailing Address - City:PINE BLUFF
Mailing Address - State:AR
Mailing Address - Zip Code:71603-7017
Mailing Address - Country:US
Mailing Address - Phone:870-535-4221
Mailing Address - Fax:870-535-4228
Practice Address - Street 1:4303 S MULBERRY ST
Practice Address - Street 2:
Practice Address - City:PINE BLUFF
Practice Address - State:AR
Practice Address - Zip Code:71603-7017
Practice Address - Country:US
Practice Address - Phone:870-535-4221
Practice Address - Fax:870-535-4228
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-18
Last Update Date:2013-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARC5066174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR104930001Medicaid
AR52592Medicare PIN
AR104930001Medicaid